INDIVIDUAL MEMBERSHIP APPLICATION

Instructions:

Please fill in all *required information.
Make your selection for payment. Fees will be processed within two days. Caregiver Marketplace is a secure site and we guarantee your information is protected.
Receipt of payment will be available for your records.
Fax or scan your signed application and send to:

Fax: 403-253-9360 Caregiver Marketplace with original signature to activate your membership .
Email: membership@caregivermarketplace.com to activate your membership

Membership fees are $30.00 & G.S.T. per person for a one year period.

*Phone number :

Fax number :

Cell phone:

*Email address:

Mailing address:

City: Province:

Postal code:

*Choose one of the following payment options:

Note: Caregiver Marketplace offers a secure site to protect your information. Fees are effective January 1, 2005

Visa MasterCard American Express

Number of Card:

Expiration Date: (mm yy)

Name on Card:

Total fees to be processed: Fees $ ________________

I, ____________________________________, do authorize activation of my membership and will allow Caregiver Marketplace to process fees on my credit card.

Authorized Signature:_______________________________________________________________

Print Name: ______________________________________________________________________

Date: ___________________________________________________________________________

I, _____________________________________________ declare the information on this application to be truthful. I do understand this application for membership is submitted for review and does not become effective until application has been approved by Caregiver Marketplace and fees are received and paid in full. I understand that this membership will become effective on the first day of the month following receipt of application and fees.

Name: __________________________________________

Signature: __________________________________________

Once membership fees have been processed, there are no prorates or refunds.

Caregiver Marketplace is a NATIONAL MEMBERSHIP PROGRAM offering a choice of affordable products, programs and services customized to support caregivers in their personal and professional growth. Please visit our website www caregivermarketplace.com
Head Office: 298 Southland Drive S.E Cagary, AB T2J 6W3
Canada and USA Toll free 1-800-486-8330